(I had call on my first night as an intern almost two years ago and as of last week I am officially and forever done with call. It’s been a long two years and I won’t miss it. I’m working the 11PM to 9AM shift in the Emergency Department this month and I marvel at how good I feel getting seven hours of sleep every day. It’s also pretty nice having a regular job again with a schedule that I can make plans around. Here are some random observations about call with a little advice thrown in for those of you who will be starting intern year in just two short months.-PB)

No Atheists in the Call Room

Despite having scoffed at religion for your whole life, disdained the faith of your parents, and professed to only believe what can be experienced by the senses, on your first night of call you will find yourself praying the universal prayer of the new intern, “Please, God, don’t let anything happen tonight.” Later, as you gain more experience, you will grow to despise call because you like to sleep. As a brand-new intern however, not only will you be too tense to sleep even if you could but your twice-weekly call nights will be anticipated with a profound sense of dread and a yearning for the simpler days when your only responsibility was to pass a measly test every couple of weeks.

Objectively it shouldn’t be that bad. Your program will point out that you are never really alone. A senior residents is always likely to be in-house with you and you can always call your attending at home if you get in over your head. No doubt this is true but as the last of the People Who Know What They are Doing leave for the night, the hospital becomes a lonely, threatening place full of patients who seemed friendly enough during the day but have now become half-dead ghouls, swaying precarioulsy on the knife edge of life, ready at any moment to shuffle selfishly off their mortal coil.

Unfortunately, you have been left you in charge of a certain number of patients and they expect a reasonable number of them to be alive when they return in the morning. If not, you’ll look like an idiot. The patients will be dead and beyond any worries. Kind of makes you regret not paying attention to ACLS in medical school. As if you were ever going to be in charge of a code.

Relax and remember the French Hooker Rule.

No matter what they want, you can only give them what you can give them. Nobody is expecting you to run the hospital. It runs on autopilot most of the time anyways. All you have to do is be attentive to your duties, make decisions that you are comfortable making, get to all the codes and if you don’t know what you’re doing, get out of the way of the people who do.

Listen to the Nurses

As you gain more experience, you will tend to roll your eyes at some of the pages you get at 3AM. You need to be polite but sometimes it’s hard to keep the “You woke me up to tell me that?” tone out of your voice.

“Dr. Bear, this is Cindy on Five South, Mr. Jones in room twelve just had a five-beat run of V-tach.”

“How’s he doing now?”

“Fine, he’s asleep and his vitals are stable.”

“Um, thanks.”

Keep in mind that she has to call you. It’s part of her protocol even though she knows more about Mr. Jones than you do, knows he has a list of life-threatening conditions that reads like the PDR, and knows perfectly well that he’s probably not going to die tonight. If on the other hand she asks you to come up to see him, well, usually it’s her long experience telling her that things are heading south and they are going to need a decision maker at the bedside. So while the tendency for a new intern is to panic and over-react to everything, even agonizing over the choice of simple pain medication renewal order, take a cue from your nurses, they know it’s July, they know you’re new, and they know you need a little guidance.

This does not apply at the VA, of course, where after five o’clock you can see tumbleweeds blowng down the corridors and the nurses vanish to some secret nurse’s lounge and are not seen until morning. I was on call there one night and a patient coded and died without anyone thinking to call me. I only found out in the morning when I walked into his room with a cheerful “Good Morning” only to see his lifeless body, endotracheal tube still in place, equilibrating with room temperature. Some people pre-write skleleton notes before they round and fill in pertinent information as they go. In this case, “Patient was without complaints,” while a completely true statement, would not quite have captured the flavor of the situation.

Stay Hydrated

Pure anecdote on my part but caffeine is over-rated. I used to drink a lot of Diet Cokes on call but it just made my jittery and, for lack of a better word, edgy. I’ve cut back considerably lately and I’ve found that good old-fashioned honest fatigue is better than the lying, cheating alertness you get from caffeine. I seem just as tired after a four or five Diet Cokes as if I just drink water, the only difference being that I yawn a little more with water.

It’s more important to stay hydrated. You can easily get mild dehydration if you’re running around all night which can be all the difference between being just tired and being physically ill. Drink water.

Oh, and avoid eating crappy food on call. Greasy fried food or sweets are going to follow you the whole night. Unfortunately, the hospital gets a good deal more casual at night and there are always cookies of doughnuts laying around somewhere. Better to have a turkey sandwich or something with some protein in it. My experience is that I always felt better on call if I ate light.

Stay Motivated

The definition of eternity is the time between midnight and five AM. If you look hard enough you can almost see the clock hands moving backwards and no matter what you do, it’s always just a little after one. In fact, it will be one AM for hours. Your brain will cry for sleep and you will be totally uninterested in the mundane crap that fills a lot of your night. At the same time your most ferverent wish will be that it’s all mundane crap. No two ways around it, call, like most of intern year blows with the power of a thousand hurricanes.

But you’re there. You’re stuck. There’s nothing to do but suck it up and make the best of things. If you have a few good friends in the same predicament you can even have a lot of madcap fun on call. Just hang out with people with a sense of humor who can appreciate the ridiculousness of the situation.

Laugh it Off

You’re going to make mistakes. Your not going to know what to do in a lot of situations. Everything is going to be difficult at first and being a real doctor is going to be nothing like you expected it to be when you were a pre-med those many long years ago but pretty much what you expected as you counted your last days of irresponsibility in fourth year. Every day and every call night will bring some secret humiliation but you have got to let it go. Don’t internalize the inevitable criticism. Sure, you’re worthless and weak, a real danger to the patients, and a jibbering, ignorant intern monkey but we’ve all been there, man. It will get better.

I promise.

Grow a Pair

There he lies, six-foot-five inches of corn-fed American manhood, a horizontal slab of sinew and muscle with a chiseled chin, tousled hair, and perfect teeth whining like a little girl because the nurse is late with his pain medications.

For God’s sake buddy, didn’t you get the memo? Of manhood, stoicism is the better part and nothing makes your fellow unreconstructed white boys cringe quite like the sight of you, otherwise unhurt, sniveling like a teenage drama queen. It’s humiliating- maybe not for you but certainly for me because you’re supposed to be storming the beaches of Iowa Jima, not alternately crying and yelling for the dilaudid that someone was fool enough to give you the first time. We expected the wide-shouldered, aggressive dialogue of a 1940s war picture but you’re giving us Cage Aux Folles instead.

The Monkey’s Other Paw

What have you done with Mr. Jones? Where has he gone? Surely this drooling, demented husk staring disinterestedly at us from his ICU bed is not our husband, our father, or our brother. Come on now, they said we were lucky, lucky to get him back at all because very few people ever come back after ten minutes of cardiac arrest. That’s why we called you people. He was just laying there twitching and then he stopped so we figured maybe he needed to be at the hospital.

But that’s not him. It doesn’t even look like him. It’s like someone else is in his skin, some shambling seedy-looking stranger who just took a swing at me. And now he just sits there and gapes malevolently. It’s creepy. Like he was on the other side of the grave long enough for something to take his place. And all he can say is “next week.”

“How do you feel?”

“Next week.”

“Can we get you anything?”

“Next week.”

Don’t you recognize us?”

“Next week.”

Seriously. Where’s the joy? The elation has pretty much evaporated, especially since you’re now telling us that he’s not going to get better. What do you mean by that? You fixed his heart, why can’t you fix his brain? Do you seriously expect us to believe that he will be crapping into adult diapers for the rest of his life and eating mushy food shovelled into his mouth by some minimum wage orderly in a fly-blown nursing home? We’re not buying it. He was mowing his own lawn last week for Christ’s sake. Sure, he smoked a little and maybe he did drink too much but he was a great guy. You should have seen how he and Uncle Frank used to cut up. It was all you could do to keep from blowing beer out of your nose.

Man. The old-fashioned kind of death was better than this.

Too Big to Live

The seat of the wheelchair is about the size of the back seat of a typical compact car. Small for a car, you understand, but big for a wheelchair and some patients barely fit. I don’t know what we’re going to do in a few years because, like old groupers living umolested in the cool deep under the pier, once you top a quarter of a ton you have no natural predators. As we’re doing our part to hold diseases at bay, there seems to be no upper limit to the size of patients.

Which would explain the in-room cranes that are now standard equipment at the best hospitals. Like gelatinous cargo, the patient is suspended from a hoist on a sturdy frame while the bed is wheeled out from underneath. An obvious solution but one I had only previously seen at sawmills where the mighty portal crane lifts massive loads of timber from the backs of trucks.

It has to be humiliating to not fit into the CT scanner and to listen to the earnest doctors and nurses, without trying to be rude, plotting a strategy to deal with your immensity. And there is reproof enough for a thousand other petty sins written in the faces of the six strong people it takes to transfer you to the bariatric hospital bed. Even the cop lends a hand.

(With apologies to Graham-PB)

AMA

Against the possibility of your thinking poorly of me, let me say at the outset that I did everything I was supposed to do and even a little more. I argued, cajoled, threatened, and I even told him the usual lies that keep people believing in our ability to cheat the reaper. I explained the seriousness of his condition and the real possibility of a choking, lonely death in his solitary bed witnessed by a glassy-eyed old cat who he told me was his only companion. If he managed to avoid this horrible death I threatened him with profound future morbidity which would finally land him in the nursing home he had struggled to avoid. I flattered him because he was a pleasant old gentleman, the last of a vanishing class, who had worked every day of his life until his first stroke cut him down. He was worth all of our efforts and I told him so.

I even worked in some of the less obvious parts of the mini-mental status exam but he was in full command of his faculties and sharper than many of our patients who were a third of his age.

It came to nothing. He decided to leave, against medical advice, and I was secretly glad. Almost elated. It was late and I was tired. I had not been looking forward to either the three pages of orders that would be required to account for all of his health problems or the lengthy admission history and physical which I would have had to write or dictate. Then there were his medications, a grocery bag full of pill bottles, that would require reconciliation, not just for the sake of paperwork but to really determine why he was taking each one, whether it was helping him, or whether it was just an ancient pharmaceutical barnacle that had attached itself during his long voyage through the tumultuous seas of modern American medicine.

He would also have required a detailed and time consuming physical exam because you just don’t casually throw your stethoscope on this kind of patient for form’s sake. He looked sick and I knew there would be many interesting physical findings, each of which would lead to decisions and tests that would have to be followed in the morning. Not to mention obtaining his old EKGs, his old films, and his old lab values to see if his renal insufficiency was acute or chronic and whether the trend of his liver enzymes portended badness.

And then there was his list of physicians, neatly typed with phone numbers, many of whom would need to be informed of his condition. I would have also needed his previous discharge summary from the hospital across town just to get a handle on what went on during his last admission. Nothing extraordinarily difficult to accomplish but all requiring attention and time.

Many patients imagine they are doing the residents a favor by letting us admit them. The truth is that the incredible administrative burden required for a typical hospital admission is a grueling chore, especially in the small hours of the morning when you can hardly keep your eyes open much less concentrate on the trivial but important details of patient care. The natural temptation at that point is to cut corners and leave it for the morning team to sort out but this is highly unethical. Everybody deserves the same level of care and the same attention to detail no matter what time they come.

And yet, what resident does not groan inwardly to himself when paged for yet another admission at 2AM and wonder why the motherfuckers can’t wait until morning? It’s just a little abdominal pain. They’ve had it for a week. Hell, they’ve had it for years. So what if it’s colon cancer? It’s not as if a few hours are going to make much of a difference.

So you try to motivate yourself for the impending chore and then comes the reprieve. He’s going AMA. Somebody usually talks them out of it but not this time. He’s a smart man and I think he’s just sick of being in the hospital eating crappy food, getting his blood drawn three times a day, and having every orifice probed with some instrument or another just to tell him that he’s living on borrowed time, something he assures me he already knows and about which he has lately become ambivalent. He only came in for a breathing treatment. He feels fine now. He likes us. He appreciates us. But no thanks.

Besides, somebody would have to feed his cat.

Baby Jail

Remember how I told you that residents are underpaid for the work they do and how we are worth a lot more to the hospital than the monthly reimbursement the hospital gets from Medicare?

Well, like most things there are exceptions and I am living that exception this month as I lollygag my way through two weeks of purgatory (for an Emergency Medicine resident anyways) in a little place called Baby Jail, otherwise known as the Regional Neonatal Intensive Care Unit. To say I do nothing and am responsible for nothing would be an understatement. It’s not even as if I could take charge and a make a great contribution if I wanted to (which I don’t) because the most excellent nurses, nurse practioners, pediatric residents, neonatology fellows, and neonatologists have that place sewn up tight. They assign me a couple of babies but it’s nothing like the adult ICU where my program’s residents run the place for the attendings and nobody actually lets me manage my babies (and I don’t want to either). As far as I’m concerned, this should be an observational rotation.

I have the greatest respect for neonatologists. The ones here are excellent and I truly believe they are doing the Lord’s work, giving every baby possible a chance at life. I may be a cynic when it comes to end-of-life care for the warm dead in the adult ICU but this cynicism does not extend to the NICU where even babies born as early as 24 weeks can sometimes (sometimes, dammit) survive and blossom as children. Still, it is decidely a low-yield rotation for us. I don’t think I’m ever going to be calculating the caloric requirements and mix of proteins and fats for a preemie. If I ever get one I’m going to slap that kid on some D10 like it says on my pocket card and get him to the nearest NICU so fast that the malpractice lawyers swarming the poor OB who delivered the baby will say, “Damn, that guy is fast.”

So every day is, if not completely unpleasant, a kind of slow torture as I follow along on rounds knowing that they know that I know that they know that I’m not really interested and am counting the days until I can do something, anything, else. I am trying to get as many lumbar punctures and other procedures as I can but that’s about the only use of the rotation. I did a month of newborn nursery last year so I know how to get the Ballard score on a baby and meaning of various hip clicks and clunks.

Please, spare me the usual rah-rah pep talk about how I need to make my job relevant and make myself useful to the attendings. The consensus of every one of our residents who have done the rotation is that residents and fellows here are great people, the work is vitally important (perhaps the most important in the whole joint) but our presence is both puzzling and useless. Some of your rotations as a resident are going to be like that. You will finally get to the point where you understand that you are covering ground over which you will never tread again.

Q24H

Mrs. Panda has taken the cubs to Florida for a week so I have had a little extra time to work on articles. It’s either that or just stare at the dogs and try to fathom their canine minds. I’ve got five of them and they’re sprawled despondantly around me waiting for the alpha female to return. The point is that I try to make all my posts about something and not just write a blurb here or there. I think even my critics will agree that this blog has a lot of content.

However, writing takes a lot out of me especially on a call-heavy month. But I plug away at it and appreciate you folks taking the time to read what I have to write. I realize some of you are clicking over here every day looking for some interesting commentary and if I could, I’d write a long article every day but I can’t. So I’ve started a page called Q24H where I’ll post brief comments, interesting (hopefully) observations, and maybe some ideas that I might later flesh out into posts. If any of you would like to contribute articles email them to me and I’ll consider putting them up. You could just post them in the comments section of an article but I think more people will read them if I post them on the Q24H page.

As usual, spelling, grammar, and voice are important. No rants, either and if I don’t use them I won’t use them but I will give you full credit when I do. Comments are not allowed in the Q24H section. It’s the “take it or leave it” page.

Comments

I think we have done a marvelous job of keeping the debate civil. I could use a little less condescension from Matthew but if that’s his style, well, it’s his style. But I am going to call him out on it. I will say that he is a policy wonk and therefore, because he understands the complexity of policy he believes that he knows more than he does. I am not a policy wonk but I understand economics and know full well that twenty years from now after almost two decades of Single Payer health care Matthew will still be wonking and still looking for somebody to blame because our people will still be unhealthy as all get out, he has to wait on grimy plastic chairs with everybody else, and the costs of his money-saving idea have ballooned to the point where nobody even remembers the good old days when we paid for our own health insurance and, in retrospect, it was pretty inexpensive.

(Just some recent questions that showed up in the mail bag.-PB)

What Exactly is Wrong With “Patient Care?” You use the phrase like it were some kind of swear word but isn’t this our purpose as residents?

Of course it is. But “Patient care” is one of those nebulous phrases which encompasses so much in it’s definition that it can mean many different things to different people. In fact, your views on patient care will be radically different depending on how much of it you do and your actual level of responsibility for patients. To the adminstrators of your hospital, patient care means shoving a warm physician body, any body, into a slot in the schedule. If this means that a resident will cross-cover a couple of hundred patients about whom he actually knows nothing then that’s acceptable because the slot is filled.

Many residents, consequently, soon get the idea that residency training has something of a cattle-drive quality to it as our job, especially on call, seems to involve nothing more than wrangling large herds of patients in and out of the hospital. So while Patient Care is the ideal and calls to mind noble images of the selfless physician tending to the afflicted, a lot of it looks and feels more like patient processing. It has to be done of course, but it’s hard to get weepy and emotional about it.

As I have mentioned before, “Patient Care” is also used as a blunt weapon to beat down any reasonable debate on hours and pay. By default, apparently, every single patient in the world would be our responsibility if the hospital could only figure out a way to keep us funtioning without sleep. From this point of view, limiting residents work hours can only be construed as a crime against humanity and for a resident to suggest that he might like to get some rest can only be viewed as rank egotism.

Oh how the hospitals must have cried righteous tears when the current 80-hour rule was implemented.

Besides Patient Care, one of your other responsibilities as a resident is to learn. Unfortunately, the current system of residency training, which would collapse if the hospital was not allowed to over-work and deprive you of sleep, is not really an ideal educational environment. This is obvious to anybody who has ever tried to crack the books when they are post-call.

What, exactly, is wrong with the current system of residency training and how would things work in the Pandaverse?

The current system of residency training was devised over a hundred years ago and has not been substantially modified since then. It evolved from a more informal system of medical training which was almost a master-apprentice relationship. In fact, until the turn of the century, medicine itself was a fairly informal enterprise with very little standardization of training. Times have changed.

My biggest criticism of residency training is that it was devised for a more lesiurely era when the pace of hospitals was a good deal slower than it is today. As I have mentioned before, there were fewer interventions, far fewer medications, and much less to be done for most patients except to observe and hope that the limited supportive care available at the time would give the patient a chance to heal. One of my attendings, for example, related to me that when he was a young resident at our hospital, there were exactly three ventilators in the entire city. One of the jobs of the medical students was to “bag” the patients until one of the ventilators could be secured, often for hours at a time.

Today, the same hospital has close to eighty fully staffed Intensive Care Beds. And they are all occupied, usually by the kind of patient who could not have existed even fifty years ago when people routinely died of things we can treat today and could never have survived to become the kind of multiply co-morbid train wrecks which are now routine. Not to mention the hundreds of regular beds that are full of people who would have been considered insanely complicated patients by our collegues from the 1950s.

This is a good thing for the most part. It is true that we tend to get a little crazy with end-of-life care, often spending hundreds of thousands of dollars to preserve the anatomical functioning of people who maybe should be allowed to die peacefully, but I’m glad that I may have the chance some day to live beyond something that would have killed me if I had been born in the nineteenth century. The result of this is, however, that the hospital has been transformed from a sleepy hotel for the sick and a minor part of the urban landscape into a bustling hive of activity, almost a small city in its own right, and often the biggest employer and largest source of economic activity for many municipalities.

And there is money to be made. Lots of it. Hospitals are money-making enterprises in a way that would have been inconcievable even sixty years ago when medical care was cheap as it didn’t require much in the way of technology or support. The amount of money flowing through hospitals is staggering and represents a substantial percentage of the Gross Domestic Product. This is not necessarily a bad thing. In fact, the economic incentive is a powerful motivator for technologies that improve the standard of living.

But it is money and it is too much to expect a bureaucrat to worship both God and Mamon. Residents, the only employees who can work almost unlimited hours without extra compensation, are an economic boon to the hospital which can only maintain a staggering volume of patients because the majority of its physicians are working for incredibly low and fixed wages. Hell, Residents cost the hospital exactly nothing as the federal government pays them an average of $110,000 per year per resident, roughly twice the cost of their pay and benefits. Hiring an extra phlebotomist is a difficult decision for a hospital and requires budgeting meetings, reams of decision support, and bureaucratic hand-wringing at the highest levels. Covering the wards at night, on the other hand, is an easy decision.

“Make the residents do it. Fuck ’em. It ain’t costing us a dime. We own those suckers and have their gonads firmly grasped.”

Imagine the heartache that would ensue if your hospital had to hire a hopsitalist to do your job.

The net result of all of these factors? Residents have been transformed from low-payed but not particularly busy apprentices working in a system set up primarily for education to low-payed and incredibly busy employees whose primary job is moving the meat and for whom education is secondary and often incidental.

The solution? For the hospital to admit that residents are employees and treat residency training how we do it in Emergency Medicine, that is, a shift system with a dedicated didactic block once a week. maybe residents need to work more than 40 hours a week but even 80 is ridiculous as it necessitates bi-weekly periods of sleep deprivation and profound fatigue that makes education almost impossible.

B-b-but Panda, you can’t possibly train a doctor without working him 80 or more hours a week as a resident. Are you saying that we need to extend residency training?

No. Residency training is hugely and completely inefficient with large blocks of your time frittered away by bureaucratic exercises that contribute nothing to Patient Care. There is, however, no incentive to change a thing in the current system. You aren’t costing your hospital a thing, remember, and even if you were laying in an ICU bed in a profound vegetative state, the hospital would still make $50,000 or so per year on your tube-fed, inert body. The ironic thing is that, with typical bureaucratic short-sidedness, the hospital could extract even more money-making (or money saving) work out of you if they streamlined things a bit.

Hey Panda, I want to do Emergency Medicine but if I can’t match into it, can’t I just match into Family Medicine and then work in Emergency Departments? It’s all just primary care, right?

Like most things, it’s all about money. As you know, Family Practice is probably the lowest payed medical specialty which also partially explains its unpopularity. Emergency Medicine pays, all other things being equal, almost twice as much as Family Practice. In the days before Emergency Medicine became a formal specialty, emergency care was rudimentary and Emergency Rooms were staffed by a motley collection of physicians of varying skill levels, some who liked working in the field and some who really couldn’t do anything else.

As the field of Emergency Medicine has evolved, however, the practice opportunities for non-board certified physicans are shrinking. Emergency Medicine has exploded in popularity (for various reasons which we will discuss in later articles) and securing a residency position leading to board certification has become increasingly difficult leading to an entry barrier to the field which many consider to be unfair.

The key question is whether you believe that Emergency Medicine is a legitimate specialty with its own unique body of knowledge that is not commonly practiced by other specialties. If it is, and I believe it is, then unless you have been working at it for many. many years before there was a specialty, you are out of luck and if you want to be an Emergency Physician, you need to get the appropriate training.

Family medicine concentrates on the diagnosis, treatment, and long-term management of common and non-life threatening conditions. Emergency Medicine deals with the diagnosis, treatment, stabilization, and short-term management of shit that can kill you sooner rather than later. Is there overlap? Sure there is. But there is overlap in every medical specialty. I do a lot of pelvic exams and know how to deliver a baby but I would never bill myself as an OB/Gyn. Where the family practioner sees the forty-year-old otherwise healthy man whose blood pressure has been creeping up and after a paternalistic discussion, prescribes him a regimine of inexpensive anti-hypertensives, the Emergency Physician sees the forty-year old alcoholic with a headache, visual changes, and a blood pressure of 240/130. The first guy can wait a few days to fill his prescription. The second guy is going to start squriting blood out of his ears shortly if nothing is done.

Now, it is true that the conventional wisdom is that Emergency Medicine is just primary care for the uninsured but this is more because the conventionally wise don’t understand what primary care is. We do see a lot of relatively minor things in the Emergency Department but these are fillers and something we do to keep busy in between the real emergencies. I did a year of family medicine. The patients I see in a normal shift in the Emergency Department, those who don’t even raise an eyebrow, are much, much sicker than anything I saw in my 48 Family medicine clinic days. We admit close to 20 percent of out patients. And a good percentage of those go to the ICU.

Can I be any less wishy-washy on the subject than that?

Not Even a Reach-Around

Residency programs should protect their residents. I’ll grant you that the long hours and low pay hard-wired into the system are not likely to be modified in my lifetime but a good program, one that is resident friendly, operates under the well-known prison rule that while I may be a bitch, I am your bitch and nobody messes with your bitch.

Unfortunately, you tend to get “passed around” a lot as a resident to services who have no regard for you whatsoever, don’t know you, will never see you again, and thus feel free to extract as much cheap labor out of you as they can.

Here’s how one scam goes down. Suppose you are a physician with no residents of your own with admitting privileges to a hospital that has residents and you have a patient who you want to admit. Traditionally, you would either send the patient to the hospital from your office with admission orders and at least a brief note or, if it was after office hours, you would come to the hospital, assess the patient, and do the usual honors. If you know there are residents however, you can get away with sending your patient to the hospital without seeing him at all and your single phone order is “Consult Medicine Service (or Pulmonary or Cardiology) for medical management.” This forces the already over-worked resident to see the patient (because his attending certainly isn’t coming in to do the consult at 10PM) and materially contributes to his work load and his sleep deprivation. The physician calling the consult can come in at his leisure the next morning and “gun deck” his note off of the usually fairly detailed consult note written by the resident. He bills for his time, the consulted service is happy because they bill for their time, and the only one with nothing to show for it is the resident who knows he’s being hosed.

I’ve been called at night by frantic nurses who have a patient directly admitted with no orders, no notes, and often only a vague idea why he is there except that the admitting doctor has asked for a consult for medical management. We generally don’t do consults until after we are finished with admissions but in some cases because it seems like a fairly dangerous enterprise to leave a potentially unstable patient in a hospital room with no orders or direction, even though the patient is not technically my responsibility I often drop what I’m doing to take care of him. And I know I’m being hosed because the admitting physician knows good and well that somebody is going to cover him.

This is different, of course, from doing a direct admission for your own service. In this case you are actually working for the attending who admits the patient and you will always get a phone call from him giving you a little guidance.

“But, Panda,” you say, “Isn’t this how you learn?”

Well, frankly, no.

You see, not every admission or consult is a wonderful learning experience. The first couple of chest pain work-ups are pretty exciting, for example, but after a while you notice that you are writing the same orders over and over with only minor variations. Everybody gets cardiac enzymes, everybody gets an EKG (which is usually normal) and everybody gets a stress test in the morning. I might as well get myself a big rubber stamp. Why my hospital doesn’t not have a standard order set for this is beyond me. This kind of thing, if nothing else, is check-box medicine at it’s finest.

But here’s the real problem. As I have mentioned before, the current system of residency training was devised almost a hundred years ago at a time when fairly little was known about physiology and treatments and studies were scarce. Hospitals were little more than boarding hotels and they remained this way until the early seventies when technology and geometrically expanding medical knowledge began to transform them into the high output patient processing units they are today. Even though the residents physicians of the early twentieth century literally lived in the hospital, it wasn’t until the early seventies when sleep deprivation became a routine part of medical training making it very difficult for a resident to both keep up with his clinical duties and study the rapidly increasing body of medical knowledge.

It is the sleep deprivation which allows the current system to function, taken as a whole, that detracts from your education. To say that going without sleep and being as sick as a dog because of it (as I often am) enhances learning is to buy into the propaganda that perpetuates the current system.

You try reading at 3AM between pages from the floor and admissions. And then see how enthusiastic you are post call to crack open Harrison’s.

Praemonitus Praemunitus

I would invite all of you, again, to visit Brother Hoover’s highly subversive little blog “MedschoolHell.” It is an entirely truthful, entertaining, and informative look at medical school of a type that you will simply not find anywhere else. Any rational person reading it would have second thoughts about medicine as a career…and yet I don’t think anyone who is serious about medical training will be deterred because you almost have to be a little insane to put yourself through this.

Hoover has also added a lot of features. The zealots among you may actually find a lot of useful information about medical school and selecting a specialty if you can contain your impulses to burn him at the stake.

If you don’t read it and find yourself in medical school regretting your decision, don’t say we didn’t warn you. I like this job. He didn’t. Doesn’t mean he has nothing to say on the subject. In fact, since you need to know the good and the bad before you make any decision in life, I don’t know why people get so irate when the less than savory aspects of medical training are discussed.

My Apologies

I have been neglecting the blog for the last month. Sorry. I had Q3 call for most of it and I’ve been tired. Please keep reading. I have a few interesting articles in the works including the first in a series of play-at-home games that will allow those of you just thinking about medical school to “kick the tires” of your potential lifestyle.

Watch for them.

Also, as always if you want to suggest a topic or just ask a question my email address can be found on the right.

Are You a Real Doctor?

They hand you your diploma and you are transformed from a medical student to a physician even though you don’t feel any different and you probably consider yourself to be something of an imposter. I know I did. For months after I graduated I had to suppress laughter whenever somebody called me “Doctor.”

This is natural. You will feel more like a real physician during the end of fourth year than you will at the start of intern year. A fourth year medical student is the dominate predator in his own isolated food chain. You don’t have much real responsibility, your residents take all the heat, and you actually do know a lot of medical trivia, much of which you will forget by the middle of intern year. Not only that but you can look with contempt at the ignorant first and second years running around and justifiably feel that you know a whole heck of a lot more than they do, both practically and philosophically. As an intern, you start with less knowledge than you had in fourth year(because medical facts have a short shelf life) but suddenly you are not only responsible for for patient care but everybody from the nurses to the techs expect you to make decisions.

You do actually exist in a parallel environment with the house staff when you are in medical school. If every medical student called in sick no one would probably notice. If the residents went on strike the hospital would grind to halt. Only the nurses are more important to actual patient care.

In fourth year you also have plenty of free time giving you ample time away from the hospital to imagine what a great doctor you will be. It’s no wonder that you feel pretty good about yourself most of the time. This has a lot to do with it being more enjoyable to pretend to be a doctor rather than being one.

So sometime early in your intern year a patient is going to accuse you of not being a real doctor and this is going to hit mighty close to home. You could lecture them about the validity of your doctorate-level degree which legitimately confers on you the title “doctor.” Deep down, however, you’ll have a suspicion that they are right…that you are some kind of poseur who slacked his way through medical school and is not worthy of the public trust.

The public who are largely ignorant of how doctors are trained fall into three broad categories. One group believed you to be a physician even while you stumbled your way through first year medical school. Parents and relatives fall into this category. My in-laws started asking me for medical advice the day after I was accepted to medical school even though pretty much everything I knew was gleaned from watching ER. They have never stopped asking me for medical advice and I find that the more I know the less I tell them, my typical response to a questions being, “You need to see your doctor.”

I’m more confident in what I know but paradoxically more humble in the realization of what I don’t.

The other group confuse medical students with residents and will never cut you any slack. These are the people who come to the hospital and ask that no residents be involved in their care under the assumption that residents don’t know anything and an attending will be better able to manage their day-to-day care. The attendings find this amusing because one of the reasons they went into academic medicine is to have a team of residents helping them with the more mundane aspects of patient care leaving them more time to devote the big picture. Not to mention that a good upper level resident is at his peak of medical knowledge. There are doctors out there who haven’t read a book or journal article since the Carter administration.

I had a patient insist that only the attending put in her central line even though I have done many of them recently and all relatively effortlessly. The attending hadn’t done one in years. He was eventually able to convince her to let me do it while he supervised.

The third group are largely ignorant of anything to do with medicine and will pour out their chief complaint to the phlebotomist if she’s wearing her white coat. It’s all the same to them. They trust authority to the point that anybody who works for the giant hospital is automatically able to solve their problems. I once walked into a patient’s room and found the patient berating a student volunteer for not writing her a prescription for pain-killers despite his protests that he was just there to get her a pillow.

So stand by. If your self esteem totally depends on what others think then you are in for a rough time. You jsut can’t please everyone. My brother-in-law who has something of a complex where I am concerned will never admit I am a doctor. He keeps moving the goal post and now insists that I will only be a real doctor when I am out of residency, not just licensed.

He’s an ass. The point is not to let this bother you. If you act like a physician, people will treat you like one. This means that you must be confident. But not reckless. If you don’t know something, admit it. It is no crime, for example, to ask the respiratory therapist for his advice. He’ll be happy to give it to you. He will also appreciate if you make a timely decision on his advice, even if it is only to consult with your senior resident or attending and get back to him quickly.

Those of us who are older have a considerable advantage because the grey hair doesn’t hurt. On the other hand I have a friend who looks 16 but has such good bearing that if he told his patients he ran the hospital they’d believe him.

Free Chow

Free food. Just another thing to consider when selecting a residency program. I’m not saying this should be one of the top three factors guiding your ranking decisions but if you have no other way to differentiate programs, I’d go with the place where you can eat for free. If you think about it, you have the potential to drop some serious money on food during almost any residency. Not to mention that it is more convenient to grab a bite at the cafeteria than to brown bag two or three meals a day.

I eat most meals at the hospital. I didn’t last year because the administration at Duke are cheap bastards and the most they could cough up was a paltry six buck on-call meal allowance at their over-priced cafeteria.

I also drink a lot of Cherry Diet Coke (the official soft drink of Panda Bear, MD), probably six or seven a day, which could otherwise be a very expensive habit if I wasn’t getting them for free.

So don’t be embarrassed to ask about this when you interview. If the cafeteria has Starbucks or equivalent coffee then you have hit the jackpot.

Call Schedules

Should you ask about call schedules when you interview or is this a sign of weakness?

Definitely ask, but ask the right people, preferably the residents and preferably at the pre-interview social event. Maybe you don’t want to seem pre-occupied with your free time when talking to the program director but, and trust me on this, by the first week of intern year almost every resident has lost whatever idealism they may have salvaged from medical school and they will perfectly understand your aversion to call and long hours.

Your call schedule will vary over the year. A standard call schedule is what is called “Q4” or every fourth night overnight call. “Q3” is not unheard of but it is difficult to stay in compliance on your hours with this kind of schedule. The surgery interns I worked with at duke were on “Q2” which meant that they did 24 hours on, 24 hours hours off. This doesn’t seem too bad but it will wear you out pretty quickly. Some more enlightened programs have Q5 or even Q6 call.

Intern year in most specialties is pretty standard as far as call is concerned. You will have a lot of call. Be sure to ask how many call months you have in the year. When I was at Duke last year I had eight months where I took call, mostly Q4. How much call you do as a PGY-2 and beyond is highly specialty dependent. Pathology, derm, and urology to name a few hardly do any in-house call after intern year and if they do, it is usually pretty benign. Medicine and Surgery, on the other hand, are call heavy for most of residency. Medicine call especially blows no matter what level resident you are.

So a good question to ask is how many call months you will take as an upper level resident. Personally, I would rank the programs highest that had the least call but that’s just me.

Also ask about night float. You want to go to a program that has night float as this usually means that the program has decided to make residency more pleasant by curtailing call, or at least making it less onerous. Generally, the night float is a resident who comes in after normal quitting time and leaves in the morning. It is a quasi-shift system as there may still be somebody on call. The night float, however, is supposed to do most of the admissions and handle most of the floor calls only waking up the on-call resident if things get really busy.

While doing cardiology at Duke, we had one week of the month on night float where we came in at seven PM and left at seven AM. Generally the on-call person got to sleep after midnight and the night float took care of business. The advantages of being on night float are legion and I would volunteer for it for all of intern year if I could. Some people don’t like it but I’ll trade vampire hours for not having to round, not having to present patients like a trained monkey, and not hanging around the hospital unsure of whether you can go home. The night float comes in, is relaxed and rested, does his job, and goes home in the morning. It is usually high quality training as you spend the night admitting patients, the key difference between this and being on call is that you are not too tired to give a rat’s ass.

A special warning about family practice residency training and something about which you should ask. Is family medicine more benign from a call point of view than, for example, medicine? Probably. But keep in mind two things. First of all, your program will likely have an inpatient service and you will pull call to admit and cover the Family Medicine patients who come to the hospital. The Family Medicine service is usually not as busy as the medicine service (unless you are at an unopposed program in which case you are the de facto medicine service) as they usually only takes bona fide family medicine patients who belong to your outpatient clinic.

I had a census of about 25 at any given time while doing pulmonary last month. The family medicine service has four or five.

A medicine service generally admits anybody from anywhere with various services taking their turn as “no doc” for the uninsured or unassigned patients.

Small or dying Family Medicine programs either have no inpatient service in which case you will spend a lot more time rotating on medicine services than you probably want to or they have home call where you can sleep at home, only coming in to admit patients. The medicine interns are usually called for overnight problems with these patients, either by formal arrangement or because the nurses know that it sometimes takes a Papal Bull to get a family medicine resident to come in. Some hospitals also don’t let Family Medicine admit or manage ICU patients which is probably another thing you need to ask about.

You will also have obstetric patients as family medicine resident and the custom is to call you in when your patient is in labor. This throws a whole new level of unpredictability into your life as you can be called in at any time to deliver one of your mothers. You will either be excited about this or you won’t but you’ve got to do it. You will also have to come in to admit your obstetric patients for other reasons besides labor. I like to think of it as having forty or fifty ticking time-bombs hidden around town any one of which can go off and ruin your weekend.

You know, sometimes when you’re managing real problems on the floor or admitting interesting and complex patients, call can almost be fun. Usually, however, it is just a grind. After you admit your fifteenth COPD exacerbation the thrill will be gone. So think about it before you rank programs.

Why Suffer?

There are two broad categories to keep in mind when selecting and ranking residency programs. One type is at a large academic teaching hospital. The other is at a smaller “community” hospital that may have only a polite affiliation with a university or even none at all.

You can get good training at either type of program but all other things being equal, life will be a lot more pleasant if you opt for a community program.

Take a big institution like Duke where I did my intern year. A good place to train. World class faculty. Impressive facilities. All of that crap that looks good on a brochure. On the other hand it is a relatively miserable place to do an intern year unless you are a robot with no interests outside of medicine. I am repeating intern year in a community program at a small regional hospital. I like it a lot better, mostly for reasons that some of you might find frivolous.

It is hard to believe that although I have no outpatient rotations whatsoever this year and have done three critical care months almost back to back, I have had more weekends off in the last four months than in my entire intern year at Duke.

At Duke, which you may take to represent big academia anywhere, they have the old-school attitude towards the house staff, namely that residents don’t deserve time off and have to earn it by becoming attendings. Thus, they make a big deal about the rare times in your schedule when you have Saturday and Sunday off. In fact, they call this a “Golden Weekend” under the insulting premise that you should be happy and grateful to have been awarded such a special treat.

At my new program, on the other hand, we have weekend call but the residents on most services decide among themselves if everybody needs to come in. We usually don’t need to. This works out to two or three full weekends off per rotation. The difference is that our attendings are usually in private practice, don’t want to come in on the weekend either, and are generally a lot more easy-going than their academic counterparts.

It’s not as if you’re going to be following the ideal model of intern education where you admit, follow, and lovingly discharge a small group of patients with whom you become intimately familiar. If that were the case, maybe it would make sense to come in every day and see how they were getting on.

In a real hospital, however, you will work on service with a steady stream of admits and discharges and it will be impossible to follow all of the patients you admit. You will dive in and out of the torrent following patients somewhat randomly. If this is the case, you may as well round on patients you don’t know over the weekend because you hardly know your own from day to day. (At most residency programs, big or small, residents are just cheap labor. Learn and understand this.)

At a small community hospital, nothing much gets done on the weekends anyways unless it is an emergency.

How about rounding? Academic physicians have the tyrant’s love for an audience. The more academic the institution, the more you will round and the longer the rounds will take, even if this is not the most efficient way to either learn or conduct business. You can learn valuable pearls of wisdom from rounding but a good deal of the time the discussion devolves to merits of competing studies which address the patient’s treatment. Fascinating stuff, no doubt, but I have no dog in the fight. I’ll follow whatever practice guidleline is eventually developed after the adults hammer things out as I am uninterested in the nuances of research.

I’m not saying that you will not round at a community program, just that the odds are your attendings will not have such a zeal for it. Remember, it is a deliberate decision to go into academic medicine. Most people do not. Odds are that if you want to work in academia you like how they do things and will trade a little bit of salary for an entourage and a team of residents to do your scutwork.

Big institutions are also a good deal more bureaucratic. Duke was almost insufferable. They have a form for everything and you can hardly wipe your ass without some kind of certification that you have completed the mandatory yearly ass-wiping seminar. This is all driven by the legal department and is part of risk management. The idea is that if you ever yell racial epithets at a patient the institution is protected from liability because they can demonstrate that you had a certain number of hours of diversity training.

They are out of control. I received almost daily notifications that some compliance requirement or another would expire in a certain number of months. The emails always ended with a sinister threat of being fired or otherwise disciplined for failure to comply.

Intern orientation at Duke took two days and I must have filled out fifty forms acknowledging that I wouldn’t sleep with patients, call them bad names, and had read and understood that surfing for porn on a Duke computer is verboten. It’s all horseshit, of course. They preach at you for an hour, you sign a piece of paper, and then you forget about it. If you’re the kind of guy who hits on patients you’re not going to be deterred by a signed disclaimer.

That’s mostly my point. They make a big deal about things that should be common sense. Everybody knows not to date patients. It happens, of course, but do I need two hours of instruction on it?

They were also mad, absolutely barking-mad, for evaluations. Quality control is great but is it necessary for any instititution to be so self-centered that they’re always asking, “How’m I doing?”

You’re doing fine. Now fuck off.

Asking for evaluations is a way to dilute responsibilty. Bureaucrats hate making decisions, especially decisions for which they will be held accountable. Evaluations and other forms of “decision support” are tools to deflect criticism if something goes wrong. Consensus is a totally gutless form of management employed by the spineless.

I suppose that ever since Press Ganey, the Fifth Horseman of the Apocalypse, issued forth from management hell it is inevitable that we will have to fill out evaluations. Smaller programs seem to have less of this and take them less seriously. Nobody at my current program has ever threatened to fire me if I didn’t turn in evaluations which did happened at Duke.

Pick your program carefully.

The Devil, for those of you wondering how he will come:

http://www.pressganey.com/